reb close, md community hospital of the monterey peninsula · chronic pain in the ed17 aaem weighs...

REB CLOSE, MD

Community Hospital of the Monterey Peninsula

The Scope of the Problem1-5

Opiate use in the US

80% of the world’s prescription opiate supply

99% of the world’s hydrocodone supply

From 1997 to 2007, the milligram per person use of

prescription opioids in the U.S. increased from 74 milligrams

to 369 milligrams, an increase of 402 percent (enough to

supply every American adult with 5mg of hydrocodone

every 4 hours for a month)

The Scope of the Problem1,2,3

7,000,000 Americans use prescription drugs

recreationally annually (2.3% of the US population)

50,000,000 Americans have used at least once during

their lifetime (16.1% of the US population)

The Scope of the Problem

Which means…that at the next Green Bay Packers

home game (Lambeau Field seats 73,000)

The Scope of the Problem

There will be

Approximately 1,700 fans in attendance recreationally using

prescription Rx this year

And approximately 11,700 fans in attendance who have or

will use prescription Rx recreationally

The Scope of the Problem2,3,5,6

Increased adverse events related to prescription drug

misuse

Estimated > 700,000 ED visits per year related to prescription

drug misuse alone

Approximately 10% of all patients on chronic opiates

account for 40% of all overdoses

Usually on high daily doses

Getting drugs from multiple prescribers

The Scope of the Problem5,6

Death from opiate overdoses have increased a factor

of 3 since the 1990s

We lose more years of productive life in the US to

prescription drug overdose than motor vehicle

accidents

The Scope of the Problem4,7,8 Prescription drug related deaths now outnumber those

from heroin and cocaine combined

Prescription drug related deaths exceed motor vehicle-

related deaths in 29 states and Washington, D.C. and

Monterey County

nearly one-third of people aged 12 and over who used

drugs for the first time in 2009 began by using a

prescription drug non-medically

Street Value

Street value

http://streetrx.com/

Street value

Per streetrx, price per pill

Hydrocodone 5 mg: $2-10

Oxycodone 5 mg: $5-100

Oxycontin (oxycodone ER) 10 mg: $10-80

Dilaudid (hydromorphine) 2 mg: $5-50

Morphine 15 mg: $5-50

Methadone 10 mg: $2-30

Tramadol 50 mg: $1-50

Street value

Per streetrx

Ativan (lorazepam) 1 mg: $1-10

Xanax (alprazolam) 1 mg: $2-20

Valium (diazepam) 2 mg: $5-10 (up to 100)

Ambien (zolpidem) 5 mg: $2-20

Street value9

Per streetrx and reference above

Some you might not expect

Seroquel (quetiapine) 25mg: $3-8

Zyprexa (olanzapine) 10 mg: $1-20

Viagra (sildenafil) 25 mg: $1-50

Street value

Phenergan with codeine

Up to $400 a pint (per Global Safety Network, 2010) – approx 500 cc

“Lean” and “Purple Drank”

Phenergan with codeine, lemon-lime soda, ice, crushed hard candies

Kaiser prescription policy

Street Value and Diversion10

Structured interviews of dealers

Opiates are the most sold

Oxycodone most popular

○ Oxy 30s most popular dose

○ Popular due to lack of filler and tylenol

Street Value and Diversion10

Pain clinic and ED shopping up and down the state

Black market for MRI

MRI forgery

Returning prescriptions back to addicted physicians

Sexual favors/illicit drugs for Rx

Street Value and Diversion10

Varying pharmacy usage

Sponsoring to increase pill yield/avoid detection

“Connects” in the health care system

As much as $40,000/month profit

Prescription Drug Montoring Programs

(PDMPs) Web-based software that allow physicians to access a

patient’s use of controlled substances

Tramadol is not controlled!!

Run state-by-state, available > 40 states

Check out the Alliance of States with prescription

monitoring programs for your state

http://pmpalliance.org/

PDMPs11-13 Do they work?

The data

Ohio-based study in 2010, ED based

Access to PDMP changed physician discharge prescribing

behavior in > 40% of cases

○ >60% prescribed fewer or no opioid medications than originally

planned

Also been shown to be useful in non-ED settings

Chronic Pain in the ED14-16

What is the role of the ED in the treatment of chronic

pain?

Chronic pain is well-established to be poorly managed

in the ED, and best managed by a single, regular,

provider

Chronic Pain in the ED15

ACEP Clinical Policy

“4. In the adult ED patient with an acute exacerbation

of noncancer chronic pain, do the benefits of

prescribing opioids on discharge from the ED outweight

the potential harms?”.

Level C recommendations:

Chronic Pain in the ED15

ACEP Clinical Policy

1. “Physicians should avoid the routine prescribing of

outpatient opioids for a patient with an acute

exacerbation of chronic noncancer pain seen in the

ED”

Chronic Pain in the ED12

ACEP Clinical Policy

2. “If opioids are prescribed on discharge, the

prescription should be for the lowest practical dose for

a limited duration (eg, < 1 week), and the prescriber

should consider the patient’s risk for misuse, abuse, or

diversion.”

Chronic Pain in the ED12

ACEP Clinical Policy

3. “The clinician should, if practicable, honor existing

patient-physician pain contracts/treatment agreements

and consider past prescription patterns from

information sources such as prescription drug

monitoring programs.”

Chronic Pain in the ED17

AAEM weighs in with similar recommendations

Narcotic analgesics are appropriate to treat acute illness or injury.

Discharge prescriptions should be limited to the amount needed

until follow-up and should not exceed 7 days worth

The patient should not receive narcotic prescriptions from multiple

doctors. Emergency physicians should not prescribe additional

narcotics for a condition previously treated in their ED or by

another physician unless there are extenuating circumstance

Patients with chronic non-cancer pain should not receive injections

of narcotic analgesics in the ED

Chronic Pain in the ED17

Emergency physicians should not prescribe long acting narcotic

agents such as oxycontin, extended release morphine or methadone.

Oxycodone, hydrocodone, and hydromorphone have high abuse

potential and the physician should consider using alternative agents

Emergency physicians should not replace lost or stolen prescriptions

for controlled substances

Emergency physicians should not fill prescriptions for patients who

have run out of pain medications. Refills are to be arranged with the

primary or specialty prescribing physician

Chronic Pain in the ED17 Narcotic pain medication is discouraged for certain conditions

including:

Back pain whether acute or chronic

Routine dental pain

Migraines

Chronic abdominal or pelvic pain and gastroparesis

Patients with suspected substance abuse behavior should be

referred to appropriate resources

If circumstances warrant, EM physicians should consider accessing

their state’s prescription data base (for states with physician access

to this)

Chronic Pain in the ED17

Patients identified with multiple ED visits for pain, problematic or

dishonest behavior (abusive, altering prescriptions, false reports or

use of multiple hospitals for pain) should be reviewed by the ED

physician leadership team which should consider the following

actions:

Sending a certified letter stating the patient will no longer be

provided narcotics in the ED

Adding an internal code (ex. 555) identifying probable drug

seeking behavior into their medical record

Chronic Pain in the ED

A quick Google search will identify many counties and states

who are enacting programs to combat this problem

Ohio

N. Carolina

Washington State (as a whole)

Illinois

Indiana

NYC

PA

San Diego

The list continues……

In Summary

Prescription drug abuse and diversion are local and

national problems that demand action

Emergency providers are constantly faced with patients

with acute and chronic pain for whom opiate or other

addictive prescriptions may be written

These prescriptions are the very ones that can be

diverted and abused

In Summary ACEP, our own professional society, is clear in their

recommendations that chronic pain should not be

managed in the ED

For acute painful conditions ACEP is also clear that short

course and lowest practical doses should be used with

attention to the risk for misuse, abuse or diversion

AAEM has published clear guidelines for emergency

providers and those are being used nationally by EDs to

address this issue

In Summary

References 1. Manchikanti et al. Pain Physician, 2008; 11: S63-88.

2. Substance abuse and Mental Health Services Administration, 2010

3. Substance abuse and Mental Health Services Administration, 2008

4. http://www.whitehouse.gov/sites/default/files/ondcp/policy-and-research/rx_abuse_plan.pdf

5. CDC. MMWR. 2011; 60: 1487-92.

6. Webster et al. Pain Med. 2011; 12: S26-35

7. http://healthyamericans.org/reports/drugabuse2013/

8. County Of Monterey. Annual Report of the Coroner 2012

9. Sansone et al. Psychiatry (Edgmont). 2010; 7: 13-16

10. Rigg et al. Drugs (Abingdon Engl). 2012; 19: 144-155

11. Baehren et al. Ann Emerg Med. 2010; 56: 19-23

12. Gilson et al. Pain Med. 2009; 10; S89-100

13. Barrett et al. J Pain Palliat Care Pharmacother. 2005; 19: 5-13.

14. Svenson et al. Am J Emerg Med. 2007; 25: 445-9.

15. Cantrill et al. Ann Emerg Med. 2012; 60: 499-525.

16. Wilsey et al. Am J Emerg Med. 2008; 26-255-63

17. AAEM Model ED Pain Treatment Guidelines

Questions?

A special thanks to Dr. Casey Grover